Right Patient, Right Place, Right Time

Introduction This study sought to compare outcomes of trauma patients taken directly from the field to a Level I trauma center (direct) versus patients that were first brought to a Level III trauma center prior to being transferred to a Level I (transfer) within our inclusive Delaware trauma system. Methods A retrospective review of the Level I center’s trauma registry was performed using data from 2013 to 2017 for patients brought to a single Level I trauma center from 2 surrounding counties. The direct cohort consisted of 362 patients, while the transfer cohort contained 204 patients. Linear regression analysis was performed to investigate hospital length of stay (LOS), while logistic regression was used for mortality, complications, and craniotomy. Covariates included age, gender, county, and injury severity score (ISS). Propensity score weighting was also performed between the direct and transfer cohorts. Results When adjusting for age, gender, ISS, and county, transferred patients demonstrated worse outcomes compared with direct patients in both the regression and propensity score analyses. Transferred patients were at increased risk of mortality (odds ratio [OR] 2.17, CI 1.10-4.37, P = .027) and craniotomy (OR 3.92, CI 1.87-8.72, P < .001). Age was predictive of mortality ( P < .001). ISS was predictive of increased risk of mortality ( P < .001), increased LOS ( P < .001), and craniotomy ( P < .001). Older age, Sussex County, and higher ISS were predictive of patients being transferred ( P < .001). Discussion Delays in the presentation to our Level I trauma center resulted in worse outcomes. Patients that meet criteria should be considered for transport directly to the highest level trauma center in the system to avoid delays in care.

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Right Patient, Right Place, Right Time: Field Triage and Transfer to Level I Trauma Centers

The American Surgeon ◽

10.1177/0003134820918249 ◽

2020 ◽

Vol 86 (5) ◽

pp. 400-406

Author(s):

Benjamin L. Gough ◽

Matthew D. Painter ◽

Autumn L. Hoffman ◽

Richard J. Caplan ◽

Cynthia A. Peters ◽

...

Keyword(s):

Propensity Score ◽

Trauma Center ◽

Linear Regression Analysis ◽

Trauma System ◽

Hospital Length Of Stay ◽

Risk Of Mortality ◽

Field Triage ◽

Increased Risk ◽

Level I ◽

Transferred Patients

Introduction This study sought to compare the outcomes of trauma patients taken directly from the field to a level I trauma center (direct) versus patients that were first brought to a level III trauma center prior to being transferred to a level I (transfer) within our inclusive Delaware trauma system. Methods A retrospective review of the level I center’s trauma registry was performed using data from 2013 to 2017 for patients brought to a single level I trauma center from two surrounding counties. The direct cohort consisted of 362 patients, while the transfer cohort contained 204 patients. Linear regression analysis was performed to investigate hospital length of stay (LOS), while logistic regression was used for mortality, complications, and craniotomy. Covariates included age, gender, county, and injury severity score (ISS). Propensity score weighting was also performed between the direct and transfer cohorts. Results When adjusting for age, gender, ISS, and county, transferred patients demonstrated worse outcomes compared to direct patients in both the regression and propensity score analyses. Transferred patients were at increased risk of mortality (OR 2.17, CI 1.10-4.37, P = .027) and craniotomy (OR 3.92, CI 1.87-8.72, P < .001). Age was predictive of mortality ( P < .001). ISS was predictive of increased risk of mortality ( P < .001), increased LOS ( P < .001), and craniotomy ( P < .001). Older age, Sussex County, and higher ISS were predictive of patients being transferred ( P < .001). Discussion Delays in presentation to our level I trauma center resulted in worse outcomes. Patients that meet criteria should be considered for transport directly to the highest level trauma center in the system to avoid delays in care.

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Impact of Traumatic Suicide Methods on a Level I Trauma Center

The American Surgeon ◽

10.1177/000313481007600211 ◽

2010 ◽

Vol 76 (2) ◽

pp. 176-181 ◽

Cited By ~ 1

Author(s):

James G. Bittner ◽

Michael L. Hawkins ◽

Linda R. Atteberry ◽

Colville H. Ferdinand ◽

Regina S. Medeiros

Keyword(s):

Trauma Center ◽

Injury Severity ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Public Health Issue ◽

Healthcare Expenditures ◽

Suicide Methods ◽

Level I ◽

Drug And Alcohol ◽

Related Mortality

Suicide is a major, preventable public health issue. Although firearm-related mechanisms commonly result in death, nonfirearm methods cause significant morbidity and healthcare expenditures. The goal of this study is to compare risk factors and outcomes of firearm and nonfirearm traumatic suicide methods. This retrospective cohort study identified 146 patients who attempted traumatic suicide between 2002 and 2007 at a Level I trauma center. Overall, mean age was 40.2 years, 83 per cent were male, 74 per cent were white, and mean Injury Severity Score (ISS) was 12.7. Most individuals (53%) attempted suicide by firearms and 25 per cent died (84% firearm, 16% nonfirearm techniques). Subjects were more likely to die if they were older than 60 years-old, presented with an ISS greater than 16, or used a firearm. On average, patients using a firearm were older and had a higher ISS and mortality rate compared with those using nonfirearm methods. There was no statistical difference between cohorts with regard to gender, ethnicity, positive drug and alcohol screens, requirement for operation, intensive care unit admission, and hospital length of stay. Nonfirearm traumatic suicide prevention strategies aimed at select individuals may decrease overall attempts, reduce mechanism-related mortality, and potentially impact healthcare expenditures.

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Five-Year Retrospective Review of Blunt Renal Injuries at a Level I Trauma Center

The American Surgeon ◽

10.1177/000313481708300214 ◽

2017 ◽

Vol 83 (2) ◽

pp. 148-156 ◽

Cited By ~ 5

Author(s):

Jessica Burns ◽

Megan Brown ◽

Zakaria I. Assi ◽

Eric J. Ferguson

Keyword(s):

Renal Injury ◽

Trauma Center ◽

Injury Severity ◽

Exploratory Laparotomy ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Free Fluid ◽

Specific Information ◽

Septic Complications ◽

Level I

We report the experience of a Level I trauma center in the management of blunt renal injury during a 5-year period, with special attention to those treated using angiography with embolization. The institutional trauma registry was queried for all patients with blunt renal injury between September 1, 2009 and August 30, 2014. Each injury was graded using the American Association for the Surgery of Trauma guidelines. Patients that underwent angiography with embolization were reviewed for case-specific information including imaging findings, treatment, materials used, clinical course, and mortality. The registry identified 48 blunt renal injury patients. Median Injury Severity Score was higher and hospital length of stay was significantly longer in those with blunt renal injury when compared with those without blunt renal injury (P < 0.001). The majority of patients with blunt renal injury were managed nonoperatively. Mortality was three out of 48 patients (5%). Nine patients underwent exploratory laparotomy. These operations were always performed for reasons other than the renal trauma (e.g., splenic injury, free fluid, free air). No patient underwent invasive renal operation. Six patients were treated using angiography with embolization. Of the six, one patient died of pulmonary septic complications. We conclude that selective nonoperative management is the mainstay of treatment for blunt renal injury. Angiography with embolization is a useful modality for cases of ongoing bleeding, and is typically preferable to nephrectomy in our experience.

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Rollover Car Crashes with Ejection: A Deadly Combination—An Analysis of 719 Patients

The Scientific World JOURNAL ◽

10.1155/2014/250540 ◽

2014 ◽

Vol 2014 ◽

pp. 1-7 ◽

Cited By ~ 4

Author(s):

Rifat Latifi ◽

Ayman El-Menyar ◽

Hany El-Hennawy ◽

Hassan Al-Thani

Keyword(s):

Trauma Center ◽

Injury Severity ◽

Admission Rate ◽

Abdominal Injuries ◽

Group I ◽

Increased Risk ◽

The Mean ◽

Car Crashes ◽

Group Ii ◽

Level I

Rollover car crashes (ROCs) are serious public safety concerns worldwide.Objective. To determine the incidence and outcomes of ROCs with or without ejection of occupants in the State of Qatar.Methods. A retrospective study of all patients involved in ROCs admitted to Level I trauma center in Qatar (2011-2012). Patients were divided into Group I (ROC with ejection) and Group II (ROC without ejection).Results. A total of 719 patients were evaluated (237 in Group I and 482 in Group II). The mean age in Group I was lower than in Group II (24.3±10.3versus29±12.2;P=0.001). Group I had higher injury severity score and sustained significantly more head, chest, and abdominal injuries in comparison to Group II. The mortality rate was higher in Group I (25% versus 7%;P=0.001). Group I patients required higher ICU admission rate (P=0.001). Patients in Group I had a 5-fold increased risk for age-adjusted mortality (OR 5.43; 95% CI 3.11–9.49),P=0.001).Conclusion. ROCs with ejection are associated with higher rate of morbidity and mortality compared to ROCs without ejection. As an increased number of young Qatari males sustain ROCs with ejection, these findings highlight the need for research-based injury prevention initiatives in the country.

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Motorcycle-related trauma: effects of age and site of injuries on mortality. A single-center, retrospective study.

10.21203/rs.2.22131/v1 ◽

2020 ◽

Author(s):

Stefano Granieri ◽

Elisa Reitano ◽

Francesca Bindi ◽

Federica Renzi ◽

Fabrizio Sammartano ◽

...

Keyword(s):

Trauma Center ◽

Injury Severity ◽

Age Groups ◽

Mortality Rates ◽

Rank Test ◽

Younger Patients ◽

Risk Of Death ◽

Increased Risk ◽

Level I ◽

The Impact

Abstract BackgroundMotorcyclists are often victims of road traffic incidents. Though elderly patients seem to have worse survival outcomes and sustain more severe injuries than younger patients, concordance in the literature for this does not exist. The aim of the study is to evaluate the impact of age and injury severity on the mortality of patients undergoing motorcycle trauma. MethodsData of 1725 patients consecutively admitted to our Trauma Center were selected from 2002 to 2016 and retrospectively analyzed. The sample was divided into three age groups: ≤ 17 years, 18-54 years and ≥ 55 years. Mortality rates were analyzed for the overall population and patients with Injury Severity Score (ISS) ≥ 25. Differences in survival among age groups were evaluated with Log-Rank test and multivariate logistic regression models were created to identify independent predictors of mortality.ResultsA lower survival rate was detected in patients older than 55 years (83,6% vs 94,7%; p = 0.049) and in those sustaining critical injuries (ISS ≥ 25, 61% vs 83% p = 0.021). Age (p =0,027; OR: 1,03), ISS (p <0,001; OR: 1,09), Revised Trauma Score (RTS) (p <0,001; OR: 0,47) resulted independent predictors of death. Multivariate analysis identified head (p <0,001; OR: 2,04), chest (p <0,001; OR: 1,54), abdominal (p <0,001; OR: 1,37) and pelvic (p =0,014; OR: 1,26) injuries as independent risk factors related to mortality as well. Compared to the theoretical probability of survival, patients of all age groups showed a survival advantage when managed at a level I Trauma Center.ConclusionsWe detected anatomical injury distributions and mortality rates among three age groups. Patients aging more than 55 years had an increased risk of death, with a prevalence of severe chest injuries, while younger patients sustained more severe head trauma. Age represented an independent predictor of death. Management of these patients at a Level I Trauma Center may lead to improved outcomes.

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Pediatric Trauma System Evaluation before and after Level II Verification

The American Surgeon ◽

10.1177/000313481908501137 ◽

2019 ◽

Vol 85 (11) ◽

pp. 1281-1287

Author(s):

Michael D. Dixon ◽

Scott Engum

Keyword(s):

Native American ◽

Trauma Center ◽

Injury Severity ◽

Life Support ◽

Pediatric Trauma ◽

Trauma System ◽

Trauma Centers ◽

Level Ii ◽

Level I ◽

Pediatric Trauma Center

ACS-verified trauma centers show higher survival and improved mortality rates in states with ACS-verified Level I pediatric trauma centers. However, few significant changes are appreciated in the first two years after verification. Minimal research exists examining verification of ACS Level II pediatric trauma centers. We analyzed ACS Level II pediatric trauma verification at our institution. In 2014, Sanford Medical Center Fargo became the only Level II pediatric trauma center in North Dakota, as well as the only center between Spokane and Minneapolis. A retrospective review of the institution's pre-existing trauma database one year pre- and postverification was performed. Patients aged <18 years were included in the study ( P < 0.05). Patient number increased by 23 per cent, from 167 to 205 patients. A statistically significant increase occured in the three to six year old age group ( P = 0.0002); motorized recreational vehicle ( P = 0.028), violent ( P = 0.009), and other ( P = 0.0374) mechanism of injury categories; ambulance ( P = 0.0124), fixed wing ( P = 0.0028), and personal-owned vehicle ( P = 0.0112) modes of transportation. Decreased public injuries ( P = 0.0071) and advanced life support ambulance transportation ( P = 0.0397). The study showed a nonstatistically significant increase in mean Injury Severity Score (from 6.3 to 7) and Native American trauma (from 14 to 20 per cent). Whereas prolonged ACS Level I pediatric trauma center verification was found to benefit patients, minimal data exist on ACS Level II verification. Our findings are consistent with current Level I ACS pediatric trauma center data. Future benefits will require continued analysis because our Level II pediatric trauma center continues to mature and affect our rural and large Native American community.

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The Impact of Methamphetamine Use on Trauma Patients at a Level I Trauma Center: A 10-Year Retrospective Review

The American Surgeon ◽

10.1177/000313481808400329 ◽

2018 ◽

Vol 84 (3) ◽

pp. 428-432 ◽

Cited By ~ 2

Author(s):

Gregory R. Stroh ◽

Fanglong Dong ◽

Elizabeth Ablah ◽

Jeanette G. Ward ◽

James M. Haan

Keyword(s):

Retrospective Review ◽

Trauma Center ◽

Traumatic Injury ◽

Hospital Length Of Stay ◽

Drug Screen ◽

Trauma Patients ◽

Urine Drug Screen ◽

Increased Risk ◽

Level I ◽

The Impact

The effects of methamphetamines (MAs) on trauma patient outcomes have been evaluated, but with discordant results. The purpose of this study was to identify hospital outcomes associated with MA use after traumatic injury. Retrospective review of adult trauma patients admitted to an American College of Surgeons verified–Level I trauma center who received a urine drug screen (UDS) between January 1, 2004 and December 31, 2013. Logistic regression analysis was used to identify factors associated with mortality. Patients with a negative UDS were used as controls. Among the 2321 patients included, 75.1 per cent were male, 81.9 per cent were white, and the average age was 39. Patients were grouped by UDS results (negative, MA only, other drug plus MA, or other drug without MA). A positive drug screen result of other drug without MA demonstrated a significantly lower risk for mortality, but longer intensive care unit and hospital length of stay, as well as increased ventilator days than negative results. Results of MA only did not alter the risk of mortality. These findings suggest that patients who test positive for MAs are not at an increased risk of in-hospital mortality when compared with patients having a negative drug screen.

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The Price of Always Saying Yes: A Cost Analysis of Secondary Overtriage to an Urban Level I Trauma Center

The American Surgeon ◽

10.1177/000313481808400854 ◽

2018 ◽

Vol 84 (8) ◽

pp. 1368-1375 ◽

Cited By ~ 1

Author(s):

Marko Bukur ◽

Candace Teurel ◽

Joseph Catino ◽

Stanley Kurek

Keyword(s):

Trauma Center ◽

Injury Severity ◽

Tissue Injury ◽

Spinal Injury ◽

Financial Burden ◽

Trauma System ◽

Soft Tissue Injury ◽

Cost Savings ◽

Urban Level ◽

Level I

Level I trauma centers serve as a community resource, with most centers using an inclusive transfer policy that may result in overtriage. The financial burden this imparts on an urban trauma system has not been well examined. We sought to examine the incidence of secondary overtriage (SOT) at an urban Level I trauma center. This was a retrospective study from an urban Level I trauma center examining patients admitted as trauma transfers (TT) from 2010 to 2014. SOT was defined as patients not meeting the “Orange Book” transfer criteria and who had a length of stay of <48 hours. Average ED and transport charges were calculated for total transfer charges. A total of 2397 TT were treated. The number of TT increased over the study interval. The mean age of TT was 59.7 years (SD ± 26.4 years); patients were predominantly male (59.2%), white (83.2%), with at least one comorbidity (71.5%). Blunt trauma accounted for 96.8 per cent of admissions with a median Injury Severity Score of nine (IQR: 5–16). Predominant injuries were isolated closed head trauma (61.4%), skin/soft tissue injury (18.9%), and spinal injury (17.6%). SOT was 48.2 per cent and increased yearly (P < 0.001). The median trauma center charge for SOT was ($27,072; IQR: $20,089–34,087), whereas ED charges were ($40,440; IQR: $26,150–65,125), resulting in a total cost of $67,512/patient. A liberal TT policy results in a high SOT rate adding significant unnecessary costs to the health-care system. Efforts to establish transfer guidelines may allow for significant cost savings without compromising care.

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Predictors of Undertriage after Major Trauma in a Physician-led Prehospital System: Insights of a French Registry

10.21203/rs.3.rs-135822/v1 ◽

2020 ◽

Author(s):

Axel BENHAMED ◽

Laurie FRATICELLI ◽

Clément CLAUSTRE ◽

Marion DOUPLAT ◽

Guillaume MARCOTTE ◽

...

Keyword(s):

Trauma Center ◽

Major Trauma ◽

Injury Severity ◽

Ultrasound Examination ◽

Trauma System ◽

Trauma Patients ◽

Medical Systems ◽

Aged Patients ◽

Increased Risk ◽

French Registry

Abstract BackgroundThe proper prehospital triage and transportation of patients suffering major trauma to lever 1 trauma centers is associated with better outcomes. Hence, emergency medical systems (EMS) aim is to avoid undertriage in these patients. The main objective of this study was to assess the rate and predictors of undertriage in a physician-led prehospital system.MethodsWe conducted an observational multicentric, region-wide, retrospective study based on the RESUVal Trauma-System registry, Rhône-Alpes region, France. All adults assessed by physician-led EMS units, from January 2011 to December 2017 with major trauma (Injury Severity Score (ISS) ≥ 16) were included. We defined the correct-triage group as major trauma patients admitted to a level I trauma center. We performed univariate then multivariate logistic regressions with undertriage as outcome.ResultsA total of 7,110 patients were included in the registry, of whom 2,591 patients with an ISS≥ 16. Among these patients, 320 (12.35%) were undertriaged. Median ISS was 25. In-hospital mortality was 16.45% (n=351/2134). Mid-aged patients (51-65 years old) were associated with a higher risk of undertriage than the others (OR=1.62, 95%CI 1.15-2.28, p=0.01). Factors associated with a lower risk of undertriage were: mechanism (fall or gunshot/stabbing wounds, 0.62, [0.45-0.86], p=0.01 and 0.44, [0.22-0.9], p=0.02, respectively), time on-scene (over 60 minutes, 0.61, [0.38-0.95], p=0.03), prehospital need for endotracheal intubation and ultrasound examination (0.53, [0.39-0.72], p<0.001 and 0.15, [0.08-0.29], p<0.001 respectively). After adjusting for severity, undertriage showed a non-significant tendency toward an increased risk of mortality (1.22, [0.8-1.89], p=0.36).ConclusionsIn our region-wide, physician-led prehospital system, undertriage of major trauma was not rare. The typical profile of undertriaged patients was a mid-aged male suffering from a blunt trauma, without respiratory distress or neurologic impairment, not benefiting from prehospital ultrasound examination and located close to a non-trauma center hospital.

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